Central Line

NEJM video guide: https://www.youtube.com/watch?v=qeVdRCqy_mo

Indications 

• RRT (CRRT or iHD), Plasmapheresis (PLEX) 
• Access for vasopressors, chemotherapy, hemodynamic monitoring (CVP, ScvO2)

Relative contraindications 

• Increased bleeding risk: Platelets should be >20K and INR <3 
• Anatomic distortion or thrombus at the target site, indwelling vascular hardware (pacemaker, HD access), vascular injury proximal to site, or skin infection

Consent 

• Immediate complications: bleeding, malposition, arterial puncture, arrhythmia, pneumo- or hemothorax, air embolism, damage to surrounding structures (nerves, thoracic duct); typically complications are <3% 
• Delayed complications: infection, thromboembolism, myocardial perforation, venous stenosis

Pre-procedural considerations 

• Must have telemetry & pulse oximetry monitoring; consider O2 for patient comfort under the drape 
• A RUE PICC doesn’t mean you can't do RIJ central line; you can have more than one line in a vessel just not at the same site. 
• With every patient, consider LENGTH OF INSERTION, LOCATION, LUMENS, and LINE TYPE!

Supplies

• Table 
• Sterile gloves, extra gown 
• Mask, hair covering, eye protection 
• Ultrasound with linear probe 
• Ultrasound probe cover (96 inch) 
• Blue cloves for line ports; for dialysis access, ClearGuard antimicrobial caps are preferred 
• Chlorhexidine preparation stick x3 
• Chlorhexidine patch 
• Central line kit, which typically includes 
  • Lidocaine, syringe, small gauge needle 
  • Catheter 
  • Saline flushes 
  • Full body Drape 
  • Skin prep solution 
  • Sterile gauze 
  • Catheter, scalpel, dilator, needle, wire 
  • Suture and needle driver 
  • Gown 
• Saline flushes (note: while saline is, the normal plastic syringes are not sterile); dispense the saline into an empty reservoir in the kit 
• Optional items: 
  • Back up or larger sterile dressing 
  • If high bleeding risk: micropuncture (mini access) kits for obtaining access, lidocaine with epinephrine

Procedural considerations 

• Confirm venous (rather than arterial) cannulation prior to dilation by 1) compression of target vessel, 2) Non-pulsatile dark blood return (unless on 100% FiO2, may be brighter red), 3) US visualization of needle and wire In short and long axis 
• Flush and lock the side ports on the line to reduce blood loss during placement 
• For IJ access, place patient in slight Trendelenburg position to engorge vein and prevent collapse while obtaining access. You can also rotate the neck to avoid the carotid being directly below the IJ. 
• While advancing needle, ensure constant negative pressure on the plunger and visualization of needle tip with US
• Designate someone to watch tele while threading guidewire to monitor for arrhythmias. Limit guidewire insertion depth to no more than 20 cm (two hashmarks) to reduce arrhythmia risk (no more than 15 cm if RIJ) 
• Always ensure guidewire is secured by your hand while it is inside a vein

Post-procedural considerations 

• Every IJ or subclavian central line needs a confirmation CXR to confirm placement and to assess for PTX 
• Ideal placement of distal tip: in SVC just outside the right atrium, approximately near/ superior to carina and right tracheobronchial angle 
• for dialysis access, tip at the CA junction is favored for highest flow rate

Troubleshooting Complications 

• Arterial Access or puncture: immediately remove needle and hold pressure for 15 mins to prevent hematoma formation (US can be used to detect persistent hemorrhage); if uncontrolled bleeding or artery was dilated, STAT vascular surgery consult. DO NOT REMOVE THE CATHETER. 
• Bleeding During or Following Access: place direct pressure; subclavian access precludes ability to compress and confers highest bleeding risk; if uncontrolled, STAT vascular surgery consult. You can place small QuikClot gauze post-procedure if needed. 
• Pulmonary Complications: if free air aspirated into syringe, consider PTX vs poor connection between the syringe & finder needle. STAT CXR to assess for PTX. If rapid deterioration, needle decompression then chest tube placement
• Venous Air Embolism: can occur if air introduced to system during placement, flushing, or if left open to the atmosphere. Effects are variable, but if suspected, place pt in left lateral decubitus position to trap air in right apex and place pt on 100% O2 to expedite resorption 
• Arrhythmia: guidewire can lead to atrial or ventricular arrhythmias; immediately withdraw wire to lesser depth; if arrythmia persists, abort procedure and treat patient and determine cause 
• Resistance to guidewire/dilator: it is not unusual to experience mild resistance during guidewire insertion, especially as more length is introduced or the needle was introduced too perpendicular to skin; but firm resistance is concerning for not being endovenous, stenosis, or thrombus. consider retracting and reintroducing; or abort and try again with finder needle to ensure correct site insertion; never forcefully advance wire or dilator